Heart disease in pregnancy

Dr. Agus Rusdhy Hariawan Hamid, SpOG SMF Obgin RSUP NTB

Pregnancy is a physiological phenomenon during which there are major cardiovascular changes affecting the loading conditions of the heart. Briefly, during the first trimester there is a steep increase in plasma volume, which causes dilution and anemia. The stroke volume and, to a lesser extent, the heart rate increase and the cardiac output increases progressively. This increase is around 4050% above the prepregnancy level and is maintained throughout pregnancy. There is an accompanying decrease in vascular resistance, and diastolic and mean blood pressure. In cyanotic or potentially cyanotic congenital heart disease, the drop in peripheral vascular resistance encourages right-to-left shunting, leading to increasing cyanosis, and a rise in hematocrit with increased risk of thrombosis and paradoxical

Normal pregnancy in a woman without heart disease is commonly accompanied by tachycardia, palpitations, and increased numbers of premature atrial or ventricular beats, sometimes multiple. It is important to recognize these usually benign symptoms.

Labour and delivery are a unique time and bring with them a degree of anxiety, apprehension, and fear for the gravid woman with cardiovascular disease and her obstetrician. Roughly 0.23% of pregnant women suffer some degree of cardiac disease and account for more than 25% of all maternal deaths. Marked changes in maternal hemodynamics occur during pregnancy: a 40% rise in blood volume, increases in uterine blood flow (low resistance shunt) to 500 ml/min at term, and marked falls in both pulmonary and systemic vascular resistance. In addition, the contracting uterus autotransfuses 300 500ml/contraction in labour and 5001000 ml of total blood in the immediate postpartum period. Cardiac output rises 33.5 l/min during the second stage and the immediate postpartum period. Average blood loss for a singleton vaginal delivery is 500 ml, and for cesarean delivery and vaginal twins it is >1000ml. Anemia, pre-eclampsia, chorioamnionitis, tocolytic therapy and hemorrhage can complicate labour and delivery by adding markedly to the increases in cardiac demand.